WHY IS AUTISM ASSOCIATED WITH AGGRESSIVE AND

Why is Autism Associated With Aggressive and Challenging Behaviors? Autism itself does not cause challenging behaviors. It is likely, however, that some of the underlying biological processes that result in autism might also result in behaviors that are outside of a person’s control—similar to how the tremors associated with Parkinson’s Disease are brought on by impulses that the person cannot direct. In addition, some behavioral responses are simply reflexes—no more of a choice for your child than when your leg jerks upward when the doctor uses his hammer on your kneecap. “Some of those behaviors that most professionals and many families would not consider challenging, such as making odd noises, repeating phrases over and over, closing and opening doors in a repetitive fashion, might not be dangerous or destructive. But they sure can be annoying, and raise everyone’s stress levels. And when the individual is told to stop again and again but still doesn’t, those little things can lead to big things. They can create a tension that makes everyone behave in ways that become problematic. Learning how to think about and deal with these low-level, irritating behaviors certainly changed how we functioned as a family and improved our quality of life.” – NM, mother In addition, the core features of autism are areas in which difficulties can lead to feelings of frustration, confusion, anxiety or lack of control, resulting in behavioral responses. Since behavior is often a form of communication, many individuals with autism (as well as those without autism) voice their wants, needs or concerns through behaviors, rather than words. This does not mean that they are always knowingly communicating. For example, running away from a barking dog might be the child’s biological fight or flight response to scary situations, or even to something that you might not view as frightening. Similarly, shutting down and retreating to a quiet place might be a child’s way of saying ‘this situation is far too noisy and crowded for me to handle.’ This may be an automatic response in the moment, not a choice he is making. Challenging behaviors are more likely to appear when a person is feeling unhappy or unhealthy. Medical concerns, mental health issues, or sensory responses that we cannot see might bring pain or discomfort to a person with autism that we might not understand, especially when he is unable to say so. “All of a sudden when Mark was about 8 years old, he needed order. The change came overnight. If we opened a cabinet, he closed it. Loading and unloading the dishwasher was impossible—he could not tolerate the door being open. It was maddening to us, and so clearly compulsive for him. He became anxious and acted out if the order was not maintained. Thankfully, our doctor ran some tests and determined that he had high antibodies to strep, and the compulsiveness was likely due to a sort of obsessive compulsive disorder called PANDAS. The biological factors were not easy to treat and took a long time to resolve, but how we responded to his behavior changed completely when we realized that he wasn’t doing this to drive us crazy, and that he was no more in control of what he was doing than we were. We worked a lot on building his tolerance for flexibility, in tiny bits and using positive rewards. Eventually, he returned to his flexible self, but we had to adapt our behavior to help him through this in a way that worked for all of us.” – SP, father PAGE 1

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Many behaviors are also responses to previous experiences. A baby who gets a smile when he coos usually learns to coo more often. The same is true for challenging behaviors. If a child has learned that screaming gets him out of a difficult task, he might scream in the future to escape. How we respond to his actions can have a significant effect on what he does the next time he is in a similar situation. Because of the learning differences that autism can bring, people with autism might need specialized approaches to learning appropriate behavior. For example, the scolding look that stops your typical two-year-old in his tracks may mean nothing to a 30-year-old with autism who has not learned to recognize emotions and facial expressions. Without some of the abilities and skills that most of us have developed as children and adults, people with autism are often just using the tools they know how to use. Therefore, it is likely that behavior can be improved by helping them to increase the tools they have available—to communicate, to recognize their own biological and behavioral responses, and to build an increased ability to self calm and self regulate.

Research on Aggression in Autism A recent study of aggression in autism showed some interesting trends in terms of risk factors, which may give some insight into challenging behaviors overall. ■ There is a much higher rate of aggression towards caregivers in autism than in the general population and in others with intellectual disabilities. ■ Unlike the risk factors in a typical population, aggression was equally common in girls as boys with autism. Several other usual risk factors (lower IQ, lower parental education, less language ability) were not associated with greater risk in autism. ■ The research also showed that just like in the typical population, age was a risk factor, with higher levels of aggression occurring at younger ages, which may suggest that learning and growth may help behaviors improve. ■ Those children with autism at highest risk of aggression exhibited the following characteristics: 1. More repetitive behaviors, especially self-injurious or ritualistic behaviors, or extreme resistance to change 2. More severe autistic social impairment These results show that core symptoms of autism are associated with the risk of aggression. Perhaps underlying conditions such as a lack of social understanding or the discomfort associated with breaking a routine might promote aggressive behavior.

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What is helpful to know about behavior? Before considering challenging behavior in isolation, it is helpful to think about human behavior in general. Some behavior is biologically driven (we eat when we are hungry) or reflexive (we cover our ears when a noise is too loud). But for the most part, behavior occurs because it serves a function and/or produces an outcome. Eating serves the function of satisfying hunger, and covering our ears softens the impact of the loud noise. Behavior also serves as a form of communication. Seeing someone cover his ears, even when we did not find a noise to be offensive, can communicate that he is particularly sensitive to sound. It is critical to remember that any individual is doing the best he can do in each situation, given his skills, education, physical and emotional state, and past experiences. We classify certain behaviors as challenging because we as individuals or a society find them to be difficult to accept. It will be important for you to become a careful observer, working to understand the purpose of behaviors. Taking a step back and considering why a person might behave in a certain way is the first important step toward understanding and learning how to help. It is also essential to reducing your own frustration. In fact, it is often helpful to think of an individual’s actions as a response, rather than a pre-determined or willful behavior. However, there is a difference between understanding behaviors that we or society might not find appropriate and accepting those behaviors. For example, determining why a child needs to kick, and then developing his skills for communication should be the objective (e.g. ‘ I need a break.’), instead of allowing kicking as a form of speech. Similarly, working to understand and treat biological conditions that might cause challenging behaviors is essential. “Sam’s teacher moved to another city, so he entered his second year of high school with a familiar but less skilled instructor. Soon he was headed to the nurse’s office each morning and spending first period on her bed. Clearly the new teacher had anxiety, and the school staff believed that this was being reflected in Sam’s behavior and increasing his anxiety as well. Or perhaps it was task avoidance, as there were a lot of language demands in that first period social skills class. Then one morning, he actually gagged and vomited, but once he got home it was clear that Sam was not sick. Soon after, other staff noticed that he would turn his head to the side and his eyes would roll during the period immediately after lunch. We also noticed a tendency to retreat to the couch at home after dinner. That’s when we consulted the gastroenterologist, and sure enough, he was diagnosed with reflux. All of these odd behaviors and the trips to the nurse’s office subsided once he was treated.” – ED, mother When thinking about your loved one with challenging behaviors, it is also important to consider his positive features and strengths. Show respect for his thoughts, feelings and the likelihood that he understands far more — or alternately, perhaps far less—than you might consider. Take care not to speak about him in his presence, for it is likely that he understands more than he is able to show. Talk to him and provide him with information, even if you are not sure that he understands what you are saying. It is important to build your child’s trust in your support, and shape his motivation and purpose into more acceptable behaviors.

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Function of Behavior Whenever behavior occurs, it is important to consider its purpose, or what is most often called its function. Although some behavior is biologically driven, much behavior is learned over time and through experiences, and shaped by what happens before and after the behavior takes place. Other behaviors may have begun as biologically driven (such as scratching an itch) but may turn into something that serves a different function (perhaps scratching to gain a teacher’s attention). “Special educators [and parents] need to look at what a child can do instead of what he/she cannot do. There needs to be more emphasis on building up and expanding the skills a child is good at. Too often people get locked into a label such as dyslexia, ADHD, or autism, and they cannot see beyond the label. Kids that get a label often have uneven skills. They may be talented in one area and have a real deficiency in another. It is important to work on areas where a child is weak, but an emphasis on deficits should not get to the point where building the area of strength gets neglected.” – Temple Grandin, Ph.D. An example of a productive behavior might be asking for something to eat, then receiving a cookie. The function of making the request is to get the cookie. For a child with limited language skills, the strategies involved in getting a cookie might look very different. But if the end result is the same, whatever the individual needed to do to be fed is the method by which he has learned to ‘get a cookie.’ Over time, an individual with significant communication challenges is likely to develop some creative and interesting methods for communicating—some of which might be considered challenging.

The Function of Challenging Behaviors Challenging behaviors, such as aggression, disruption, or self-injury are often a chief concern of caregivers of individuals with autism and other developmental disabilities. Many of these challenging behaviors are learned and maintained by what happens immediately before and after the problem behavior. Because they are learned behaviors, problem behaviors can be modified by manipulating or changing situations in the environment, especially the events before and after the problem. In most cases, challenging behavior is seen as a way to request or communicate a preferred outcome (e.g., access to toys, food, social interaction, or cessation of unpleasant activity). Therefore, the goal is to replace the inappropriate “request” with more adaptive (appropriate and effective) communication. -p.13 Targeting the Big Three Questions you might ask about why a person is behaving in a certain way include: ■ Did this behavior start suddenly? If so, might my child be sick or is there another change that might have caused this? ■ Is there some underlying medical concern or condition that is making him reactive? Tired? Stressed? ■ What is my child attempting to gain from this behavior? Is he trying to escape something? ■ What is he trying to tell me? What can I learn from this? ■ Does it happen in certain places, with specific people or in situations where he is hungry or tired? Is there something we might adjust in his surroundings that might improve the situation? PAGE 4


■ What happens before the behavior? Is there something that makes it more likely to occur? ■ What happens after the behavior occurs? What is helping this behavior persist? What maintains it or makes it work as a tool for this individual? ■ What do I typically do to get my child to stop engaging in the behavior? Am I (or is someone else) giving him more attention then, or doing something that might be making the behavior work to get him what he wants? If you can develop an idea of when or why a behavior is happening, you may realize there are simple solutions that help to improve a situation and make an undesired behavior less likely to occur. It is also essential to remember that behavior changes, and people adapt. The same behavior that serves a specific function in one situation may serve a different purpose in another setting. In other words, one bite might be out of frustration when a child wants something he is unable to ask for. Another might occur when he is afraid and needs to get away, and yet another might be an automatic response to intense stress. And although biting is the same behavior, the reasons it happens (the function) can be very different. Behavior generally serves one of several functions: ■ Obtaining a desired object or outcome ■ Escaping a task or situation ■ Getting attention, either positive (praise) or negative (yelling) ■ Trying to self-calm, self-regulate or feel good (sensory input) ■ Blockingor staying away from something painful or bothersome (sensory avoidance) ■ Responding to pain or discomfortAttempting to gain control over an environment or situation (self-advocacy) Improvements can often be made by changing the situations and environment, or the things that come before and after problem behaviors occur. And since behavior is often a form of communication, teaching more adaptive and appropriate ways of communicating can often reshape problem behaviors into more appropriate requests, protests and responses. “Before I was able to express myself with my speech, the only way I knew how to escape from situations and people I didn’t like was to hit and bite and run. I didn’t want to hurt anyone, but I just couldn’t stand being there anymore and I couldn’t explain my thoughts or feelings in any other way. So many things bothered me, it was like being in intense pain. Now that I’ve had years of practice – first with signing and then my communication device – I can use my speech and other forms of communication to ask for a break or to move to a quiet space, instead of using aggression. Things are much better for me now.” – DR, a young woman with autism Before formal interventions are developed, it is important to consider the wide array of possible contributing factors, including the biological ones. Appropriately determining function is then essential to creating a plan that might effectively address the behavior. PAGE 5


For example, if a child is hitting his mom in order to get out of making his bed, putting the child in ‘time out’ would actually give the child what he wanted (avoiding the task), and therefore support (reinforce) the behavior. In this case, he would be inclined to hit again to escape. Instead, if it is determined that the child hits because the task is too difficult, making the task easier to build success might allow him to stay engaged, and eliminate the need to hit. You may want to start by helping him make the bed, but be sure that he has to finish the job correctly by putting on that last pillow. In considering behavior, it is important to look at the individual as a whole, and to consider productive as well as challenging or maladaptive behaviors. It is also important to recognize that what we might consider negative behavior might have positive elements—the individual might be standing up for his wants or desires. Building appropriate self-advocacy and self-determination skills is essential. Visit the Positive Strategies for Supporting Behavior Improvement for more information. People with autism often report that they find the world confusing and anxiety-producing. Many of the successful supports for increasing appropriate behavior involve creating more predictability and safety, while also building self-regulation, communication and self-determination skills. Meet your child where he is now, celebrate the things he does well, and take small, positive steps to build the skills and the trust that will make him more adapted to your family and the world around him.

Two Vital Things to Remember By applying the principles of behavior, you will teach the individual a more appropriate way to obtain what she wants (i.e., attention, access to leisure materials, or avoiding doing a task, etc.). ■ Consistency is Vital - While function-based behavior intervention can be very effective, for it to be most successful, it must be implemented consistently at all times by the majority of people who interact with the individual. ■ Continuation is Vital - More importantly, the behavior intervention should continue even if the challenging behavior begins to decrease, much like the way medication or diet works. Hoping for a lasting effect without continuing the changing agent (i.e., behavior treatment, medication, and diet) will only lead to frustration and failure. With consistency and adherence to the behavioral guidelines, you will see gradual change in the individual’s challenging behavior. –Page 72 – Targeting the Big Three

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WHY IS AUTISM ASSOCIATED WITH AGGRESSIVE AND

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